My declaration of entitlement and eligibility
(for public funding)
I am residing permanently in New Zealand. (plan to be in New Zealand for at least 183 days in the next 12 months)
Yes No
Please tick which eligibility criteria applies to you:
I am a New Zealand Citizen I hold a resident visa or a permanent resident visa (or a residence permit if issued before December 2010). I am an Australian citizen or Australian permanent resident AND able to show I have been in New Zealand or intend to stay in New Zealand for at least 2 consecutive years. I have a work visa/permit and can show that I am able to be in New Zealand for at least 2 years (previous permits included). I am an interim visa holder who was eligible immediately before my interim visa started. I am a refugee or protected person OR in the process of applying for, or appealing refugee or protection status, OR a victim or suspected victim of people trafficking. I am under 18 years and in the care and control of a parent/legal guardian/adopting parent who meets one criterion in clauses a-f above OR in thee control of the Chief Executive of the Ministry of Social Development I am a NZ Aid Programme student studying in NZ and receiving Official Development Assistance funding (or their partner or child under 18 years old) I am participating in the Ministry of Education Foreign Language Teaching Assistantship scheme I am a Commonwealth Scholarship holder studying in NZ and receiving funding from a New Zealand university under the Commonwealth Scholarship and Fellowship Fund None
Please upload your evidence (i.e. Passport, Visa, Birth Certificate, proof of employment or study course, etc) - suggestion: scan and add, or take a photo and attach.
Browse Files
Cancelof
Take Photo of your evidence (i.e. Passport, Visa, Birth Certificate, etc)
Take Photo of your evidence - if you need another photo
Community Services Card
Yes No
CSC number
CSC Expiry date
Day Month Year
Date
Enrollment
I understand that by enrolling with this practice I will be enrolled with the PHO -Primary Health Organisation (PHO Name). My name, address and other identification details will be included on both the practice and PHO enrolment registers.
I understand that if I visit another provider where I am not enrolled, I may be charged a higher fee.
I have been given information about the benefits and implications of enrolment with the PHO and their contact details.
I have read and I agree with the Health Information Privacy Statement in the accompanying PHO information booklet.
I agree to inform the practice of any change in my eligibility.
Enrollment Type
I choose to enroll with this practice as my regular general practice Casual or Visitor Only
Transfer of Records - In order to get the best care possible, I agree to the Practice obtaining my records from my previous Doctor. I also understand that I will be removed from their practice register.
Yes, please request transfer of my records No transfer Not applicable
Name of previous Doctor
Name of previous Medical Practice
Previous Medical Practice Address (if known)
Signature
Clear
Date
Day Month Year
Signed by
Patient Authorised Person (Parent or Caregiver to sign if under 16 years)
Name of authorised Person with legal right to sign for this patient:
First Name Last Name
Relationship:
Should be Empty:

Enrolment Form